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A nurse is assisting a patient to change an ostomy appliance when they note the stoma is protruding into the bag. What would be the nurse's first action in this situation?
- A. Reassuring the patient that this is a normal with a new ostomy
- B. Notifying the health care provider that the stoma is prolapsed
- C. Having the patient rest for 30 minutes to see if the prolapse resolves
- D. Replacing the appliance with a larger appliance
Correct Answer: C
Rationale: A protruding stoma suggests prolapse; the first action is having the patient rest for 30 minutes (C) to see if it resolves. Reassuring (A) is incorrect as prolapse isn't normal, notifying the provider (B) is premature, and a larger appliance (D) doesn't address the issue.
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A nurse is administering a large-volume cleansing enema to a patient prior to surgery. When the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next?
- A. Elevating the head of the bed 30 degrees and repositioning the rectal tube
- B. Placing the patient in a supine position and modifying the amount of solution
- C. Lowering the solution container and checking the temperature and flow rate
- D. Removing the rectal tube and notifying the primary care provider
Correct Answer: C
Rationale: Severe cramping during an enema suggests the solution is too cold or the flow rate is too fast. Lowering the container and checking temperature and flow rate (C) addresses this. Elevating the bed (A) or changing position (B) doesn't resolve cramping, and removing the tube (D) is premature.
A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test?
- A. Having the patient consume a low-fiber diet several days before the test
- B. Having the patient take bisacodyl and ingest a gallon oral polyethylene glycol solution (PEG)
- C. Preparing the patient for the use of general anesthesia during the test
- D. Explaining that barium contrast mixture will be given to drink before the test
Correct Answer: A
Rationale: A low-fiber diet several days before a colonoscopy (A) reduces residue in the colon. PEG is used, but bisacodyl (B) isn't standard for all preps. Conscious sedation, not general anesthesia (C), is typical, and barium (D) is for other GI tests.
A nurse asks a patient for a stool sample to perform the guaiac test. How does the nurse best explain the purpose of this test?
- A. This test replaces the need for screening colonoscopy.
- B. We are looking for infectious organisms in your stool.
- C. The screening assesses for blood in your stool.
- D. This test assesses for antibodies to colon cancer.
Correct Answer: C
Rationale: The guaiac test (C) detects occult blood in stool, screening for GI bleeding or cancer. It doesn't replace colonoscopy (A), detect organisms (B), or assess antibodies (D).
A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure, the patient tells the nurse they are feeling dizzy and nauseated and then vomits. What should be the nurse's next action?
- A. Reassuring the patient that this is a normal reaction to the procedure
- B. Stopping the procedure, preparing to administer CPR, and notifying the primary care provider
- C. Stopping the procedure, assessing vital signs, and notifying the health care provider
- D. Pausing the procedure, waiting 5 minutes, and then resuming the procedure
Correct Answer: C
Rationale: Dizziness, nausea, and vomiting suggest vagal stimulation. Stopping the procedure, assessing vital signs, and notifying the provider (C) is appropriate. Reassuring (A) ignores the risk, CPR (B) is premature, and resuming after 5 minutes (D) is unsafe without assessment.
A nurse working on a GI unit is caring for a group of patients. In patients with which health problems or issues could the assessment possibly reveal decreased or absent bowel sounds after listening for 2 minutes? Select all that apply.
- A. Peritonitis
- B. Prolonged bedrest
- C. Diarrhea
- D. Gastroenteritis
- E. Early bowel obstruction
- F. Postoperative paralytic ileus
Correct Answer: A,B,F
Rationale: Decreased or absent bowel sounds indicate reduced motility, common in peritonitis (A), prolonged bedrest (B), and paralytic ileus (F). Diarrhea (C), gastroenteritis (D), and early bowel obstruction (E) typically cause hyperactive bowel sounds due to increased motility.